Early Walking in Brace Better for Achilles Tendon Rupture

Athletes who experience an Achilles tendon rupture want to get back to the game as soon as possible and now data from the UKSTAR trial published in The Lancet (“Treatment decisions for acute Achilles tendon ruptures”) suggests that early walking in a brace is the way to do it.

Researchers from the University of Oxford and the University of Warwick reveal that early walking in a brace provides similar outcomes to plaster casting with no additional complication risks.

“This research is particularly important for sportsmen and women of all levels and abilities,” said Matthew Costa, Professor of Orthopaedic Trauma Surgery at NDORMS, University of Oxford. “Achilles tendon rupture keeps people away from sport for many months. For some, it stops them ever returning to their favourite recreational activities, and for professional athletes it can be a career-ending injury. Immediate mobilization in a brace is a safe alternative to plaster casting after an Achilles rupture and patients report better early outcomes, probably because the brace allows them to walk earlier than the cast.”

When a non-operative approach is indicated for an Achilles tendon, either a plaster cast that immobilizes the foot and ankle or functional bracing that allows for weight-bearing is recommended. Before this study, there was no real data on which approach was more effective, although long term immobility in cast has been associated with long-term mobility issues including gait abnormalities and muscle weakness.

On the flip side though, there have also been concerns with bracing including re-rupturing of the tendon. In their 2009 guidelines, the American Academy of Orthopaedic Surgeons were not confident in recommending for or against functional bracing.

In this multicenter study in the United Kingdom, funded by the National Institute for Health Research, however, the researchers found that the risk of re-rupture of the tendon in bracing was actually lower than what had been reported before.

Costa said, “Traditionally, patients with a rupture of the Achilles tendon are immobilised for several weeks in a plaster cast which restricts their mobility. However, our new research shows that immediate weight-bearing in a walking boot allows the tendon to heal just as quickly and with no increase in the risk of further rupture. Plus, the walking boot treatment is cheaper for the NHS [National Health Service].”

Rebecca Kearney who is an academic physiotherapy lead at Warwick Clinical Trials Unit was also involved in the study and she added, “This research is answering a question that has been debated for over a decade; early research began at the University of Warwick in 2009 exploring the impact of plaster casts and walking boots on walking patterns and getting back to activities, which led to the development of this trial. We now know that patients who immediate weight bear in a walking boot have better early outcomes, but this is only the beginning of the recovery. We need to do further research exploring how we best rehabilitate patients after the walking boot is discarded. This trial highlighted large variation in rehabilitation provision across the UK for this injury.”

The UKSTAR trial included 540 participants from 39 UK hospitals that were randomized to either a plaster cast or functional brace after Achilles tendon rupture. Re-rupture rates as well as function, pain and quality of life scores were all assessed. The researchers found no difference in patient-reported Achilles Tendon Rupture Score at 9 months or in the rate of re-rupture of the tendon.